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Report a Safeguarding Concern

Name of person completing this form*

Role/Position

Your email*

Your phone number*

Person of concern (full name)*

Date and time of incident:*

Day

Month

Year

Time

:HoursMinutes

Location of concern*

Nature of Concern

Physical injury/abuse

Emotional wellbeing

Neglect

Online safety concern

Allegation against staff/tutor/volunteer

Other (please specify)

Describe the concern (facts only – what was seen, heard, or disclosed)*

Names of anyone else present

Immediate Actions Taken*

Reassured the learner

Reported to Safeguarding Lead

Contacted emergency services

Recorded concern only

Other

External agencies notified/involved (include date and time notified)

Did the individual disclose harm or risk directly?

Yes

No

Were any injuries visible? (If applicable)

Yes

No

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